Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke

JHN Journal Volume 10 | Issue 1 Article 1 Winter 2015 Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke Anthony P. Kent, BA Sidney Kimmel Medical College, Thomas Jefferson University, Maria Montano, MPH Sidney Kimmel Medical College, Thomas Jefferson University, Nohra Chalouhi, MD Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Badih Daou, MD Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Robert H. Rosenwasser MD Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital of Neuroscience, See next page for and additional authors works at: https://jdc.jefferson.edu/jhnj Follow this additional Let us know how access to this document benefits you Recommended Citation Kent, BA, Anthony P.; Montano, MPH, Maria; Chalouhi, MD, Nohra; Daou, MD, Badih; Rosenwasser MD, Robert H.; Tjoumakaris, MD, Stavropoula l.; and Jabbour, Pascal MD (2015) "Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke," JHN Journal: Vol. 10 : Iss. 1 , Article 1. DOI: https://doi.org/10.29046/JHNJ.010.1.001 Available at: https://jdc.jefferson.edu/jhnj/vol10/iss1/1 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in JHN Journal by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: . Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke Authors Anthony P. Kent, BA; Maria Montano, MPH; Nohra Chalouhi, MD; Badih Daou, MD; Robert H. Rosenwasser MD; Stavropoula l. Tjoumakaris, MD; and Pascal Jabbour MD This review article is available in JHN Journal: https://jdc.jefferson.edu/jhnj/vol10/iss1/1 Kent, BA et al.: Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke Anthony P. Kent BA1*, Maria Montano MPH1*, Nohra Chalouhi MD2, Robert H. Rosenwasser MD2, Stavropoula I. Tjoumakaris MD2, Pascal Jabbour MD2 Anthony P. Kent BA1*, Maria Montano MPH1*, Nohra Chalouhi MD2, Badih Daou MD2, Stavropoula I. Tjoumakaris MD2, Robert H. Rosenwasser MD2, Pascal Jabbour MD2 *Both authors contributed equally 1 Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA 2 Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA ± 3 days. Tracheostomy was performed in 36% and percutaneous endoscopic gastrostomy (PEG) 63% of subjects. An IVC filter was placed in 25% of subjects. Overall, subjects were hospitalized for 22 ± 17 days. The mean MRS score at 90 days post-DH was 4 ± 1 characterized as moderately severe disability. Mortality (MRS = 6) at 90 days post-DH was 18%. DISCUSSION BACKGROUND Background Patients presenting with large ischemic strokes may develop uncontrollable, progressive brain edema that risks compression of brain parenchyma and cerebral herniation.1 Edema that does not respond to medical treatment necessitates decompressive hemicraniectomy (DH) as a life-saving procedure. The functional outcome of patients is uncertain and the patient’s family is presented with the difficult decision of intervention with DH. While the functional outcome of patients is not worsened by DH,2 neurological deficit is likely as a result of initial large-territory ischemia. The correlation of specific clinical variables preceding DH to patient outcome helps inform clinicians and families about prognosis.3 This study identifies an array of clinical variables in patients who underwent DH for ischemic stroke in order to investigate potential predictors of functional outcome. The present analysis describes the clinical variables and functional outcome in patients who underwent DH subsequent to severe cerebral edema that resulted from ischemic stroke. The characteristic patient was male, clinically overweight with a history of hypertension, and presenting with an NIHSS > 10 implicating the right MCA. Cases involving intervention with tPA or endovascular therapy did not preclude the need for DH. The midline shift is serially monitored by neuroradiology for patients with cerebral edema. The peak value was collected, with a mean shift of 9 mm prior to intervention with DH. Although the mean time from stroke onset to DH was 3 days, it was possible for DH to occur at a max of 35 days. Depending on the severity of stroke patients required tracheostomy for ventilator assistance, and PEG tube placement to provide a route for adequate nutrition. The incidence of deep vein thrombosis (DVT) and requirement for placement of an IVC filter was not uncommon during the in-patient recovery period, which is likely related to venous blood stasis and comorbidity in the setting of prolonged immobilization. After total hospitalization for nearly a month subjects were typically discharged to a rehabilitation center or nursing home. At 90 days post-DH most patients had disability requiring assistance (MRS 3 - 5), a minority of patients (4%) were considered functionally independent (MRS = 2), and 18% of patients METHOD A total of 1,624 subjects that underwent any type of craniectomy from 2006 to 2014 were retrospectively screened via electronic medical record. The specific selection criterion was DH secondary to ischemic stroke involving the middle cerebral artery (MCA), internal carotid artery (ICA), or both. Subjects were excluded if they underwent craniectomy for any reason other than DH for ischemic stroke; or if the MCA or ICA were not implicated. The clinical variables that were collected may be divided into pre-DH and post-DH. The pre-DH variables involve patient demographics and past medical history, in addition to clinical variables during the period of presentation and clinical management leading up to DH. The post-DH variables describe the in-patient recovery period and discharge status. The primary outcome was functional status assessed by the Modified Rankin Scale (MRS) score at 90 days post-DH. The MRS ranges from 0 (no symptoms) to 6 (death) with intermediate values (1-5) representing increasing functional and cognitive disability. RESULTS There were N = 95 subjects who presented with ischemic stroke involving the MCA (72%), ICA (7%), or both MCA+ICA (...truncated)